EMCrit Project

. Introduction:  Perpetual controversy . The use of magnesium for AF has been a controversial topic for decades.  Magnesium is a normal electrolyte, so it is cheap and has an excellent safety profile.  Ironically, this is also magnesium’s Achilles heel, because this has caused the pharmaceutical industry to have no interest in it.  This leaves […]

  . Introduction . In 2008 and 2013, two prospective RCTs from Greece reported benefits from the combination of vasopressin, steroids, and epinephrine (VSE) for in-hospital cardiac arrest.  However, other studies investigating the addition of vasopressin alone to epinephrine have been negative.  Consequently, vasopressin has been removed from the AHA/ACC algorithms, with a specific recommendation […]

[PLEASE NOTE:  For the most complete & updated material on alcohol withdrawal, please see the Internet Book of Critical Care Chapter on this topic here] Case example   . A middle-aged man was admitted to the ICU for refractory alcohol withdrawal.  Prior to arriving in the ICU he had been treated aggressively with an escalating […]

. Introduction . Resuscitation with large volumes of normal saline (NS) causes hyperchloremic metabolic acidosis.  Some evidence suggests that hyperchloremic metabolic acidosis may impair renal function, but the clinical relevance of this remains unclear.  If hyperchloremic metabolic acidosis is truly detrimental, this would be one argument to use balanced crystalloids rather than NS.  . . […]

. A perplexing case . A young man with a history of seizures and alcoholism presented with a generalized seizure.  His seizure responded to lorazepam, but he was intubated for airway protection and was transferred to the Genius General ICU.  He was also loaded with levtiracetam to prevent further seizures.  . Overnight he developed agitation.  Despite […]

  . Case: An unusual ICU referral . Some years ago at Genius General Hospital, the ICU was asked to accept a patient from the medicine ward with cirrhosis, confusion, and hyponatremia (Na 125 mM) for hypertonic saline therapy.  There was concern that the patient’s confusion was due to his hyponatremia.  . Chart review showed […]

. Introduction with a case . Imagine an elderly patient presenting with hypovolemic hyponatremia (sodium of 115 mM) and moderate confusion.  How would you treat this patient? . The typical approach might be a slow infusion of 3% sodium chloride.  The presence of neurologic symptoms supports the use of hypertonic saline.  However, patients with hypovolemic […]

. Introductory case . A young 70-kg man was transferred to the Genius GeneralICU for management of stupor.  He had been diagnosed with aortic valve endocarditis due to heroin abuse two weeks earlier, but left the hospital against medical advice.  Shortly after admission to Genius General, the lab called with a critical sodium value of […]

. An elderly man was admitted to the ICU and evaluated by six blind physicians. . The blind cardiologist noted that the patient had a malignant pericardial effusion with tamponade.  She recommended an immediate pericardial drain followed by intra-pericardial chemotherapy. . The blind oncologist noted that the patient had stage IV lung cancer.  He recommended […]

  . Case example . A previously healthy 45-year-old man was transferred to the Genius General Hospital ICU for management of pneumonia.  He was intubated prior to transfer due to hypoxemia (details unavailable).  His chest radiograph showed dense right lower lobe consolidation, which was confirmed with ultrasonography.  He was treated with a regimen of dexamethasone, […]

Introduction  . Community-acquired pneumonia (CAP) remains the leading cause of infectious disease death in developed countries.  Described by Sir William Osler as “captain of the men of death,” it dates back to antiquity.  However, we are only beginning to understand the best ways to treat it.   . Part 1:  The Pneumococcal meningitis story . Ceftriaxone […]

Introduction with a case . A 45-year-old man was transferred to the Genius General Hospital ICU for management of pneumonia.  His chest radiograph is shown above.  Chest ultrasonography showed extensive consolidation of the entire right lower lobe with dynamic air bronchograms (video below).  He was treated with ceftriaxone and azithromycin.  . Extensive lobar consolidation with […]

. Introduction . Suppose you just placed the central line shown above.  Does it need to be repositioned?  . I was trained that the tip of the central line must lie in the lower portion of the superior vena cava.  If the line was in the right atrium, it would cause cardiac perforation.  If the […]

. Introduction . In 2012 a NEJM article by Ray et al. reported a correlation between azithromycin and cardiovascular death.  This received extensive press and ultimately led the FDA to issue a drug safety communication warning about the risk of QT prolongation and torsade de pointes.  Subsequent studies have failed to replicate this result.  Nonetheless, […]

. . Introduction . The Surviving Sepsis Campaign has raised awareness that septic shock is a medical emergency.  However, these guidelines recommend a stepwise approach to resuscitation, which commonly results in a gradual escalation of treatment intensity.   Additional therapies are added over several hours if the patient fails to reach treatment goals.  For some patients, […]